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  ========================LICENSE_START=================================
  screenit-web
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  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
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  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
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  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
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  You should have received a copy of the GNU Affero General Public License
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  =========================LICENSE_END==================================
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<html xmlns:wicket="http://wicket.apache.org">
<wicket:panel>
    <div class="modal-header">
        <button data-dismiss="modal" class="close" type="button">x</button>
        <h3>Huisarts uit vorige ronde</h3>
    </div>
    <div class="modal-body">
        <div style="display: block;" id="bevestigen" class="form-container huisarts-bevestigen">
            <h2>Huisarts bevestigen</h2>
            <div class="form-horizontal">
                <div class="control-group value">
                    <label class="control-label">Naam huisarts</label>
                    <div class="controls" wicket:id="huisartsNaam">Vries, H. de</div>
                </div>
                <div class="control-group value">
                    <label class="control-label">Praktijknaam</label>
                    <div class="controls" wicket:id="praktijkNaam">
                        Huisartspraktijk de Kameleon
                    </div>
                </div>
                <div class="control-group value">
                    <label class="control-label">Adres</label>
                    <div class="controls" wicket:id="praktijkAdres">
                        Plaats 9a <br> 8224AB Lelystad
                    </div>
                </div>
                <div class="control-group value">
                    <label class="control-label">Telefoonnummer</label>
                    <div class="controls" wicket:id="telefoonnummer">0320-222506
                    </div>
                </div>
                <div class="control-group value">
                    <label class="control-label">AGB-Code huisarts</label>
                    <div class="controls" wicket:id="huisartsAgb">12345678</div>
                </div>
                <div class="control-group value">
                    <label class="control-label">AGB-Code praktijk</label>
                    <div class="controls" wicket:id="praktijkAgb">12345678</div>
                </div>
                <div class="control-group value">
                    <label class="control-label">E-Novation klantnummer</label>
                    <div class="controls" wicket:id="klantnummer">50000123</div>
                </div>
                <div class="control-group value">
                    <label class="control-label" wicket:message="title:title.edifactadres">EDI-fact adres</label>
                    <div class="controls" wicket:id="ediadres">50000123@lms.lifeline.nl</div>
                </div>
                <div class="control-group value">
                    <label class="control-label" wicket:message="title:title.communicatieadres">Communicatieadres</label>
                    <div class="controls" wicket:id="communicatieadres">50000123@lms.lifeline.nl</div>
                </div>
            </div>
        </div>
    </div>

    <div class="modal-footer">
        <a style="display: block;" id="terugNaarZoekenBtn"
           class="btn pull-left" href="javascript:void(0);" wicket:id="terug">Andere huisarts selecteren</a>
        <button data-dismiss="modal" class="btn" wicket:id="annuleren">Annuleren</button>
        <button id="huisartsOpslaanBtn" data-dismiss="modal"
                class="btn btn-primary" wicket:id="opslaan">Selecteer
        </button>
    </div>
</wicket:panel>
</html>
